1336203231 NPI number — ERIC N KING O.D

Table of content: ERIC N KING O.D (NPI 1336203231)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336203231 NPI number — ERIC N KING O.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KING
Provider First Name:
ERIC
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336203231
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 US HIGHWAY 150 BYP
Provider Second Line Business Mailing Address:
SUITE 117
Provider Business Mailing Address City Name:
STANFORD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40484-1034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-365-2195
Provider Business Mailing Address Fax Number:
606-365-2195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 US HIGHWAY 150 BYP
Provider Second Line Business Practice Location Address:
SUITE 117
Provider Business Practice Location Address City Name:
STANFORD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40484-1034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-365-2195
Provider Business Practice Location Address Fax Number:
606-365-2195
Provider Enumeration Date:
12/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  KY1294DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5281470001 . This is a "PALMETTO PROVIDER ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 77012946 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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